Infectious Disease Mycology

Dr.Kedar Karki
 Dimorphic Systemic Mycoses

• These are fungal infections of the body

caused by fungal pathogens which can
overcome the physiological and
cellular defences of the normal human
host by changing their morphological
form. They are geographically
restricted and the primary site of
infection is usually pulmonary,
following the inhalation of conidia.
 Dimorphic Systemic Mycoses

Disease Causative organisms Incidence

Histoplasma capsulatum
Histoplasmosis Rare*
Histoplasma dubosii

Coccidioidomycosis Coccidioides immitis Rare*

Blastomycosis Blastomyces dermatitidis Rare*

Paracoccidioidomycosis Paracoccidioides brasiliensis Rare*

Sporotrichosis Sporothrix schenkii Rare

Penicilliosis marnefffei Penicillium marneffei Rare*

 Dimorphic Systemic Mycoses

• Histopathology is especially useful and is

one of the most important ways of alerting
the laboratory that they may be dealing
with a potential pathogen.
 Tissue morphology of dimorphic pathogens:

Mycosis Tisue morphology

Large broad base unipolar budding yeast cells (8-

Blastomycosis
10um).

Coccidioidomycosis Spherules (10-80um) with endospores (2-5um).

Small narrow base budding yeast cells (1-5um; 5-

Histoplasmosis
2um in var. duboisii)

Large narrow base, multi-budding yeast cells (20-

Paracoccidioidomycosis
60um).

Sporotrichosis Small narrow base budding yeast cells (2-5um).

Opportunistic Systemic Mycoses

• These are fungal infections of the body

which occur almost exclusively in
debilitated patients whose normal
defence mechanisms are impaired.
The organisms involved are
cosmopolitan fungi which have a very
low inherent virulence.
Opportunistic Systemic Mycoses

• The increased incidence of these infections

and the diversity of fungi causing them, has
parallelled the emergence of AIDS, more
aggressive cancer and post-transplantation
chemotherapy and the use of antibiotics,
cytotoxins, immunosuppressives,
corticosteroids and other macro disruptive
procedures that result in lowered resistance
of the host.
Opportunistic Systemic Mycoses

Disease Causative organisms Incidence

Candida albicans and
Candidiasis Common
related species.
Cryptococcosis Cryptococcus neoformans Rare/Common
Aspergillosis Aspergillus fumigatus etc. Rare
Pseudallescheriasis Pseudallescheria boydii Rare
Zygomycosis ( Rhizopus, Mucor, Rhizomucor,
Rare
Mucormycosis) Absidia etc.
Penicillium, Paecilomyces, Beauveria,
Hyalohyphomycosis Rare
Fusarium, Scopulariopsis etc.
Cladosporium, Exophiala, Wangiella,
Phaeohyphomycosis Rare
Bipolaris, Exserohilum, Curvularia.
Penicillosis marneffei Penicillium marneffei Rare
Hyalohyphomycosis Description:

• A mycotic infection of man or animals caused by

a number of hyaline (non-diatomaceous)
hyphomycetes where the tissue morphology of
the causative organism is mycelia. This
separates it from phaeohyphomycosis where the
causative agents are brown-pigmented fungi.
Hyalohyphomycosis is a general term used to
group together infections caused by unusual
hyaline fungal pathogens that are not agents of
otherwise-named infections; such as
Aspergillosis. Etiological agents include species
of Penicillium, Fusarium.
 Clinical manifestations:

• The clinical manifestations of

hyalohyphomycosis are many ranging from
harmless saprophytic colonization to acute
invasive disease. Ideally, individual disease
states involving invasive fungal infection by
a hyaline hyphomycete should be designated
by specific description of the pathology and
the causative fungal genus or species (where
known); for example "pathology A" caused
by "fungus X".
 Predisposing factors
• Predisposing factors include prolonged
neutropenia, especially in leukemia
patients or in bone marrow transplant
recipients, corticosteroid therapy,
cytotoxic chemotherapy and to a lesser
extent patients with AIDS. The typical
patient is granulocytopenic and
receiving broad-spectrum antibiotics
for unexplained fever.
 Laboratory diagnosis:

• 1. Clinical material: Skin and nail

scrapings; urine, sputum and bronchial
washings; cerebrospinal fluid, pleural
fluid and blood; tissue biopsies from
various visceral organs and indwelling
catheter tips.
 Laboratory diagnosis:

• 2. Direct Microscopy: (a) Skin and nail

scrapings, sputum, washings and
aspirates should be examined using
10% KOH and Parker ink or calcofluor
white mounts; (b) Exudates and body
fluids should be centrifuged and the
sediment examined using either 10%
KOH and Parker ink or calcofluor white
mounts,
 Direct Microscopy:
• (c) Tissue sections should be stained
using PAS digest, Grocott's
methenamine silver (GMS) or Gram
stains. Note hyphal elements are often
difficult to detect in H&E stained
sections.
 Interpretation:
• The presence of hyaline, branching
septate hyphae, similar to Aspergillus in
any specimen, from a patient with
supporting clinical symptoms should be
considered significant. Biopsy and
evidence of tissue invasion is of particular
importance. Remember direct microscopy
or histopathology does not offer a specific
identification of the causative agent.
 3. Culture:
• Clinical specimens should be inoculated
onto primary isolation media, like
Sabouraud's dextrose agar.
Culture of Chrysosporium [left] and Fusarium [right] showing typical
colony colour
for a hyaline hyphomycete ie any colour except brown, olivaceous
black or black.
 5. Identification:
• Culture characteristics and microscopic
morphology are important, especially
conidial morphology, the arrangement of
conidia on the conidiogenous cell and the
morphology of the conidiogenous cell.
 4. Serology:
• There are currently no commercially
available serological procedures for the
diagnosis of any of the infections classified
under the term hyalohyphomycosis.
 AspergillosisDescription:

• Aspergillosis is a spectrum of diseases of humans and

animals caused by members of the genus Aspergillus.
These include (1) mycotoxicosis due to ingestion of
contaminated foods; (2) allergy and sequelae to the
presence of conidia or transient growth of the organism
in body orifices; (3) colonisation without extension in
preformed cavities and debilitated tissues; (4) invasive,
inflammatory, granulomatous, narcotising disease of
lungs, and other organs; and rarely (5) systemic and
fatal disseminated disease. The type of disease and
severity depends upon the physiologic state of the host
and the species of Aspergillus involved. The etiological
agents are cosmopolitan and include Aspergillus
fumigatus, A. flavus, A. niger, A. nidulans and A. terreus.
 Clinical manifestations:

• 1. Pulmonary Aspergillosis: including

allergic, aspergilloma and invasive
aspergillosis.
• The clinical manifestations of pulmonary
aspergillosis are many, ranging from
harmless saprophytic colonisation to acute
invasive disease.
 AspergillosisDescription:

• Allergic aspergillosis is a continuum of clinical entities

ranging from extrinsic asthma to extrinsic allergic
alveolitis to allergic bronchopulmonary aspergillosis
(hypersensitivity pneumonitis) caused by the inhalation
of Aspergillus conidia. Features include asthma,
intermittent or persistent pulmonary infiltrates, peripheral
eosinophilia, positive skin test to Aspergillus antigenic
extracts, positive immunodiffusion precipitin tests for
antibody to Aspergillus, elevated total IgE, and elevated
specific IgE against Aspergillus. Plug expectoration and
a history of chronic bronchitis are also common.
Symptoms may be mild and without sequelae, but
recurrent episodes frequently progress to bronchiectasis
and fibrosis.
 1. Pulmonary Aspergillosis:
including allergic, aspergilloma
and invasive aspergillosis.
• Non-invasive aspergillosis or aspergilloma
(fungus ball), is caused by the saprophytic
colonisation of pre-formed cavities, usually
secondary to tuberculosis or sarcoidosis.
Features often include hemoptysis with blood
stained sputum, positive immunodiffusion
precipitin tests for antibody to Aspergillus, and
elevated specific IgE against Aspergillus.
However, many cases are asymptomatic and
are usually found by routine chest
roentenogram.
 Acute invasive pulmonary
aspergillosis
• . Predisposing factors include prolonged neutropenia,
especially in leukemia patients or in bone marrow
transplant recipients, corticosteroid therapy, cytotoxic
chemotherapy and to a lesser extent patients with AIDS
or chronic granulomatous disease. Clinical symptoms
may mimic acute bacterial pneumonia and include fever,
cough, pleuritic pain, with hemorrhagic infarction or a
narcotising bronchopneumonia. The typical patient is
granulocytopenic and receiving broad-spectrum
antibiotics for unexplained fever. Radiological features
may be non-specific and tests for serum antibody
precipitins are also usually negative. Clinical recognition
is essential as this is the most common form of
aspergillosis in the immunosuppressed patient.
Chronic narcotising aspergillosis
• Chronic narcotising aspergillosis is an indolent,
slowly progressive, "semi-invasive" form of
infection seen in mildly immunosuppressed
patients, especially those with a previous history
of lung disease. Diabetes mellitus, sarcoidosis
and treatment with low-dose glucocorticoids may
be other predisposing factors. Common
symptoms include fever, cough and sputum
production; positive serum antibody precipitins
may also be detected.
 Disseminated Aspergillosis:

• . Hematogenous dissemination to other visceral

organs may occur, especially in patients with
severe immunosuppression or intravenous drug
addiction. Abscesses may occur in the brain
(cerebral aspergillosis), kidney (renal
aspergillosis), heart, (endocarditis, myocarditis),
bone (osteomyelitis), and gastrointestinal tract.
Ocular lesions (mycotic keratitis, endophthalmitis
and orbital aspergilloma) may also occur, either
as a result of dissemination or following local
trauma or surgery.
 4. Cutaneous Aspergillosis:

• Cutaneous aspergillosis is a rare

manifestation that is usually a result of
dissemination from primary pulmonary
infection in the immunosuppressed
patient. However, cases of primary
cutaneous aspergillosis also occur, usually
as a result of trauma or colonisation.
Lesions manifest as erythematous
papules or macules with progressive
central necrosis.
 Laboratory diagnosis:

• 1. Clinical material: Sputum, bronchial

washings and tracheal aspirates from
patients with pulmonary disease and
tissue biopsies from patients with
disseminated disease.
 Laboratory diagnosis:

• 2. Direct Microscopy: (a) Sputum,

washings and aspirates make wet mounts
in either 10% KOH & Parker ink or
Calcofluor and/or Gram stained smears;
(b) Tissue sections should be stained with
H&E, GMS and PAS digest. Note
Aspergillus hyphae may be missed in H&E
stained sections. Examine specimens for
dichotomously branched, septate hyphae.
Aspergillosis of the lung.

showing
dichotomously branched,
septate hyphae (left) and a conidial head of A. fumigatus (right).
 Interpretation:
• The presence of hyaline, branching
septate hyphae, consistent with
Aspergillus in any specimen, from a
patient with supporting clinical symptoms
should be considered significant. Biopsy
and evidence of tissue invasion is of
particular importance. Remember direct
microscopy or histopathology does not
offer a specific identification of the
causative agent.
 3. Culture:
• Clinical specimens should be inoculated
onto primary isolation media, like
Sabouraud's dextrose agar. Colonies are
fast growing and may be white, yellow,
yellow-brown, brown to black or green in
colour.
A. fumigatus growing in air sacs of
a hen during
epidemic aspergillosis in poultry.
 Interpretation:
• Aspergillus species are well recognised as common
environmental airborne contaminants, therefore a
positive culture from a non-sterile specimen, such as
sputum, is not proof of infection. However, the detection
of Aspergillus (especially A. fumigatus and A. flavus) in
sputum cultures, from patients with appropriate
predisposing conditions, is likely to be of diagnostic
importance and empiric antifungal therapy should be
considered. Unfortunately, patients with invasive
pulmonary aspergillosis, often have negative sputum
cultures making a lung biopsy a prerequisite for a
definitive diagnosis.
 4. Serology:
• Immunodiffusion tests for the detection of
antibodies to Aspergillus species have proven to
be of value in the diagn.osis of allergic,
aspergilloma, and invasive aspergillosis.
However, they should never be used alone, and
must be correlated with other clinical and
diagnostic data. Mixed and individual antigenic
extracts and antisera to the common Aspergillus
species are commercially available from a
number of sources. Reliable antigen detection
tests for invasive aspergillosis are currently not
available.
 Identification:
• . Aspergillus colonies are usually fast growing, white,
yellow, yellow-brown, brown to black or shades of green,
and they mostly consist of a dense felt of erect
conidiophores. Conidiophores terminate in a vesicle
covered with either a single palisade-like layer of
phialides (uniseriate) or a layer of subtending cells
(metulae) which bear small whorls of phialides (the so-
called biseriate structure). The vesicle, phialides,
metulae (if present) and conidia form the conidial head.
Conidia are one-celled, smooth- or rough-walled, hyaline
or pigmented and are basocatenate, forming long dry
chains which may be divergent (radiate) or aggregated in
compact columns (columnar). Some species may
produce Hülle cells or sclerotia.
 Causative agents:

• Aspergillus flavus,
• Aspergillus fumigatus,
• Aspergillus nidulans,
• Aspergillus niger,
• Aspergillus terreus.
 Aspergillus flavus on Czapek dox agar. Colonies are granular, flat,
often with radial grooves, yellowat first but quickly becoming bright to

dark yellow-green with age.

 Aspergillus niger

Microscopic morphology of Aspergillus niger

showing large, globose, dark brown conidial heads,
Aspergillus fumigatus
 Microscopic morphology of Aspergillus fumigatus showing
typical columnar, uniseriate conidial heads. Conidiophores
are short, smooth-walled and have conical shaped terminal
,
vesicles
 Management:

• Management depends on the type and severity of

infection and on the immunological status of the patient.
Allergic aspergillosis is usually controlled by using
prednisone because it is effective in reducing symptoms.
Aspergilloma or fungus ball of the lung requires surgical
resection, usually a lobectomy to ensure complete
eradication. Treatment of other more invasive forms of
infection usually requires a combination of surgical
resection and treatment with high dose amphotericin B
[1.0 mg/kg per day]. Liposomal amphotericin B
(AmBisome) is much better tolerated and doses as high
as 3-5 mg/kg per day have been given without serious
side effects. Itraconazole [400 mg/day] is often used as
adjunctive therapy or for maintenance therapy to prevent
relapse